As the COVID-19 pandemic rages globally, the African continent has not been severely affected. Overall, Africa – a continent of 1.2 billion people – has reported 9,310 cases. Looking at Nigeria, despite being the most populated country in Africa, it has just reported 232 cases, 5 deaths and discharged 32. As encouraging as Nigeria's COVID-19 situation is, however, it is very possible that cases are being missed, especially along Nigeria's land borders.
As a public health physician in Nigeria, I have worked in communities along these land borders and seen firsthand how porous they are. Some of them are farmlands, some are forests while some are parts of households. Apart from a few portions that serve as official crossings, the land borders are pretty much open for all. This has always bothered me, and I have spoken about this weakness previously.
Countries located around Nigeria's vast land borders include Cameroon (north east and south east); Republic of Benin (north west and south west); Chad and Nigeria's Republics (northern) and the Atlantic Ocean via the Bight of Biafra (Southern). As at April 5 2020, these countries reported the following numbers of cases of COVID-19: Cameroon (306); Niger (98) Benin (13) and Chad (8).
With closure of international borders in the country, public health authorities had heaved a sigh of relief and focused on tracing and testing more than 6,000 people who were exposed to COVID19 as a result of international travels and their contacts. Then, on April 1, 12 new COVID-19 cases were reported in Nigeria's south west state of Osun. These cases were Nigerians traveling by road from the neighboring Republic of Benin. This highlights the risks that exist along Nigeria's vast international borders.
Indeed, Nigeria's land borders have been part of the country's weakest link in epidemic preparedness for a long time and now must be prioritized in order to stem the count of COVID-19 cases. These are four ways to markedly reduce the threat of importing COVID-19 and other infectious diseases through these land borders.
First, train communities located along Nigeria's international land borders in risk communication, so they understand how infectious diseases are spread, who to call when cases are suspected and their roles in preventing transmission of infectious diseases, including COVID-19. There are lessons to learn from a surveyconducted by EpiAFRIC in 2016 at Idiroko - a border community located between Nigeria and Benin Republic. A total of 397 questionnaires were administered in the survey. The result showed that 36% believe that spiritual healers can cure or treat infectious diseases; 33% say that they drink traditional herbs to avoid germs; and 63% do not know who to contact to report a suspected case of Ebola to ask questions. Fifty-three percent agree that land crossing at Ipokia should be closed if there is any outbreak in neighboring countries; 67% trust the government/ministry of health to give reliable health information to them; and 78% chose radio, television (67.5) and Facebook (35.5%) as preferred sources of information on infectious diseases.
Second, increase cross-border collaborations between national public health institutes, port health, customs and immigration services in all countries involved. To mitigate the occurrence of infectious disease, they must collaborate to share data, learnings and intelligence. For instance, the lack of such collaborations may be the reason for these recent COVID-19 cases that came in from Benin Republic. Joint training of officers from these different arms of government is also very important. This would ensure the officers establish personal as well as official relationships that could improve information sharing.
Third, improve access to healthcare in border communities and engender positive health-seeking behaviors. When community members fall sick, the first place they should go for healthcare is within the public health system. As it currently stands, data show otherwise - chemists and community pharmacies are the first places people seek care. In fact, Nigeria's 2016 national health accounts showed that total health expenditure was $10 billion: out-of-pocket expenditure was $7.7 billion and $2.6 billion of out-of-pocket expenditure was spent in chemists and pharmacies (this was more than twice the total donor health support in same year). Any communities along these land borders without universal access to healthcare is a weak link in prevention, detection and prevention of infectious diseases.
Fourth, train drivers who convey passengers along these international land borders on epidemic preparedness. They must be educated on their roles in preventing cross-border transmission of infections. This training is for their good too because their close proximity to passengers exposes them to COVID-19 and other infectious diseases.
Tackling the limitations of Nigeria's vast land borders would not happen overnight. However, government, civil society, the private sector, donor-funded programs, health workers and community leaders must begin to prioritise this intervention one community at a time.
Infectious diseases do not respect borders. Public health interventions should not too.
Dr. Ifeanyi M. Nsofor, is a medical doctor, a graduate of the Liverpool School of Tropical Medicine, the CEO of EpiAFRIC and Director of Policy and Advocacy at Nigeria Health Watch. He is a a Senior New Voices Fellow at the Aspen Institute, a Senior Atlantic Fellow for Health Equity at George Washington University, and a 2006 International Ford Fellow. You can follow Ifeanyi on Twitter @ekemma.